Provider Demographics
NPI:1144598228
Name:SPROUT VENTURES, INC.
Entity Type:Organization
Organization Name:SPROUT VENTURES, INC.
Other - Org Name:SPROUT CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:GOMBIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSMFT, LCPC, BCN
Authorized Official - Phone:312-794-5582
Mailing Address - Street 1:221 E CULLERTON ST
Mailing Address - Street 2:UNIT 101A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1386
Mailing Address - Country:US
Mailing Address - Phone:312-794-5582
Mailing Address - Fax:312-794-5579
Practice Address - Street 1:221 E CULLERTON ST
Practice Address - Street 2:UNIT 101A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1386
Practice Address - Country:US
Practice Address - Phone:312-794-5582
Practice Address - Fax:312-794-5579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007708101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty